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Evaluation and Management (E&M) Leveling Policy: Effective July 24, 2026
Ambetter·KY·Provider Bulletin
Effective date
Jul 24, 2026
We identified it
Aug 26, 2026
Summary
Ambetter from WellCare of Kentucky will implement automated E&M leveling review effective July 24, 2026, applying national CPT and CMS guidelines to physician office visit and emergency department E&M codes. The payer will evaluate high-level E&M services based on diagnostic information and recode claims to the appropriate service level, potentially resulting in payment adjustments for overcoded claims. Providers must ensure E&M services are coded according to AMA CPT Manual and CMS Documentation Guidelines to avoid claim denials or recoding.
Action Required
By July 24, 2026: Billing team and providers must review and align all E&M coding practices with AMA CPT Manual and CMS 'Documentation Guidelines for Evaluation and Management' standards. (1) Audit current E&M coding patterns to identify any high-level (99214, 99215, 99285, etc.) office visit or ED claims that may be overcoded; (2) Retrain all providers and clinical staff on proper E&M code selection based on medical decision-making complexity, time, and documented visit elements; (3) Update encounter templates and EMR documentation workflows to ensure providers document sufficient detail to support the E&M level assigned; (4) Review peer benchmarking data and compare your practice's E&M distribution against specialty norms to identify outliers; (5) Implement internal audits of E&M coding before claim submission. Failure to comply will result in Ambetter recoding claims to lower E&M levels, reducing reimbursement and potential audit findings. Contact your Provider Relations Representative with questions. Reference Policy Numbers CC.PP.066 and CC.PP.076.